Blog entry by Arif Khwaja
With the epidemic of type 2 diabetes, obesity and an ageing population much of modern day nephrology focusses primarily on cardiovascular risk management - i.e. blood pressure, lipid and glycaemic control. One question I've always asked myself is whether the traditional model of a patient visiting a doctor in a clinic at two to three monthly intervals is clinically useful or cost effective. Many of the lifestyle interventions such as diet, exercise, stopping smoking, salt restriction etc dont actually require specialist clinical input whilst for many patients algorithms for BP, lipid or glycaemic control are relatively simple and well established through national guidelines. Indeed in the UK, some specialist nurses appropriately trained in prescribing having taken on an important role managing diabetes and hypertension in primary care. Furthermore it is clear that in middle and low income countries ( where there is a real epidemic of non-communicable diseases (NCDs)) such a doctor-centric model of care is simply not financially viable.
In this weeks Lancet there is an interesting analysis of the Iranian approach to NCDs with an analysis of their approach to rural primary health care. Their model known as the Behvarz system uses trained community health care workers to serve rural populations. These workers are trained for 2 years and receive a salary that is 1/6th that of a doctors salary. Between 1996 and 2002 as part of a national action plan for the prevention and control of diabetes, Behvarz workers were trained to identify those at high risk of diabetes, provide lifestyle advise and follow up those diagnosed with diabetes to monitor for complications and promote adherence and identify patients who are running into problems to doctors . Data from the NCD surveillance survey in 2005 ( a large health examination survey of nearly 90,000 individuals aged between 15-64) was combined with socio-economic data and data on the density of Behvarz workers to study the impact of the scheme. Treatment reduced plasma glucose by 1.34 mmol/l in rural (i.e. Behvarz areas) compared to 0.21 mmol/l in urban areas. With respect to blood pressure the results were slightly better in urban areas though its important to appreciate that blood pressure management had not been incorporated into the Behvarz system.
Whilst the study is not a RCT of two different models of care this large, high quality dataset makes interesting reading. The better control of diabetes in rural areas did seem to be related to the use of Behvarz workers who perhaps played a key role in ensuring adherence to therapeutic plans. If healthcare systems around the world are to rise to the challenge of NCDs then we will need to develop alternative, cost-effective models of care - and we will need to challenge whether what doctors do can be delivered (or complemented) by other healthcare workers in a more cost-effective way.
see Farzadfar and colleagues http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61349-4/abstract